Jason Altmire [00:00:04]:
Welcome to another edition of Career Education Report. I'm Jason Altmire. We talk a lot on this program about the skills gap across various professions. And nowhere do you see more commentary or more importance placed upon the skills cap than you do with regard to nursing in the country. And there was a recent government report that estimated this year alone there will be a shortage of 70,000 registered nurses and that number will continue to grow. So we wanted to bring on a guest who had expertise in that issue and has worked to solve that problem and has a lot to say. And she is Dr. Karen Cox.

Jason Altmire [00:00:48]:
She's president of Chamberlain University and she has also in the past served as the president of the American Academy of Nursing, in addition to many other significant roles in nursing. So, Dr. Cox, thank you for being with us.

Karen Cox [00:01:03]:
Thank you, Jason. Look forward to it.

Jason Altmire [00:01:05]:
Can you talk a little bit about why is there a nursing shortage? Because I know you work in this every day and have spent your entire career in it. I visit nursing schools all across the country. It seems to me there's a lot of interest in nursing. There's a lot of very talented students out there and great schools producing graduates into the workforce. And to some it might seem unusual that given the momentum in producing nurses in this country, we still have an enormous shortage and it's projected to grow in the future. Why is that?

Karen Cox [00:01:42]:
Well, just to start with, a lot of people think that this is, for the most part as a result of the pandemic and certainly that heightened the issue of shortage. However, we don't have a shortage of nurses. There are 4 million registered nurses in the US and if they were all practicing in direct care full time or even part time, we would have what we needed and we'd have enough to replace and add physicians. What's happened over time is the work of a nurse in direct care has become very difficult. It's hard physically. You have a lot of important decisions that you're in a place to make even as new graduates. And you have to deal with patients and their families and often at a very difficult time for them. And so sometimes it's difficult to establish that relationship.

Karen Cox [00:02:40]:
The other thing people don't talk about is one reason it's gotten harder is because of the weight of our nation. People weigh more. And so for me to help a 50 year old man up out of bed who just had a knee replacement whose normal weight versus one who weighs a hundred pounds more, that's wearing. And the other thing is the reality is that a lot of people with chronic illness who are in the hospital, are in that weight category. So it's become physically challenging for people, mentally exhausting and there's the cycle of people coming and going. And so one of the things that we have done is treat nurses for quite a while more as commodities than the trusted and skilled professionals they are. And so it's set up a lot of different dynamics that people don't think about. And so you have people that go into nursing practice, indirect care for a while and then there's lots of other jobs they can take where they get paid more or it's, it's easier from a just physical lifestyle, hours of work perspective.

Jason Altmire [00:03:58]:
Can you talk a little bit about there's some confusion among some of the different types of nurses, the different level of Nursing Credential LPNs versus Ben's registered nurses. What, what do all those signify and what does that mean for the future with regard to solving some of these issues you just mention?

Karen Cox [00:04:20]:
First of all, I started my career as a licensed practical nurse or lpn and it's a one year program typically at a votech or community college. And you learn how to do a lot of things. You don't learn as much about the why behind it. It's a technical role is how I would call it. Then for an rn, for example, at Chamberlain, we only grant right now the BSN and we will take people with an associate's degree in nursing and get them through a BSN online. So it really, at the end of the day there's the two levels because despite different opinions, just a little over half of the nurses graduated in the last couple of years have been bsn, which is new. It's been uneven in the other direction for licensed practical nurses. I think it's a good pathway.

Karen Cox [00:05:20]:
I'm not sure it's a great job for future for long term. So it's for me, it helped me gain confidence that I could go to an associate's degree program at the community college and be successful. But because of the acuity we see now in hospitals, the roles utilize less now with that said, in the pandemic, people were hiring anyone they could with a license. So LPNs did see a bit of a comeback. I'm not sure that it will be sustained. The BSN is kind of the gold standard. And the best part about getting a bsn, when you're talking about college and there's a lot of discussion about higher ed and debt, you make a very good salary. The minute you finish that three year program, you have a bachelor's degree.

Karen Cox [00:06:13]:
And so if you did take out loans, you're in good shape to repay them. So the value of a BSN is pretty significant.

Jason Altmire [00:06:23]:
The government study that I referenced was the Health Resources and Services Administration, which estimates a 78,000 shortage of full time registered nurses. So given what you just said, what does it mean to be a registered nurse in the context of your education?

Karen Cox [00:06:41]:
You can be a registered nurse with an associate's degree or with a bachelor's degree. So at this point we're licensed the same way, so we take the same licensing exam.

Jason Altmire [00:06:55]:
And Chamberlain University is the largest provider of nursing education programs in the country. So can you talk a little bit about the scope of what we're talking about? How many nurses are produced by Chamberlain?

Karen Cox [00:07:08]:
Yep. So Chamberlain has really two separate segments. We have the pre licensure, which is someone coming in with no degree in nursing and they go through a three year program to get a bsn. The other part of the organ, the university, are post licensure and college of Health professions. So it's people getting their, their nurse practitioner certification, master's degree, their dnp, physician assistant, master's in social work. But on the pre licensure side, those are net new nurses. We have a little over 15,000 students currently at 23 campuses across 15 states and a BSN, a pre licensure, BSN online. So.

Karen Cox [00:07:54]:
So to put it in perspective, in the previous year There are about 1,000 schools that grant the BSN in the U.S. about 5% of BSNs came out of Chamberlain and the rest, all the other schools. So it's significant in scope. The other thing that's significant is the diversity of our students. We have our diversity is about 60%. And the other thing that is significant is that it's becoming a bit of an elite profession in nursing because it's hard to get in. So there are fewer slots than we need and more interest. And so what schools do is they up the gpa and that keeps them in the place they want to be.

Karen Cox [00:08:47]:
And as our AT Tallum CEO Steve Beard always likes to say, most elite universities want to be known by who they keep out. We want to be known by who we bring in, and not just bring in, but bring in to be successful and really help them. So, you know, you may have a 3.2 GPA and you're a wonderful nurse. It's how you apply yourself in the program and your aptitude and all of those things. We also have a group of students that work full time and are often independent. So they have to take care of others and that's why they work. And often the nursing program is maybe their second or third priority in their life. And that's a burden.

Karen Cox [00:09:33]:
And that takes a different kind of faculty and a different kind of support than you might see at a more traditional university where, where somebody is, their school's paid for and they went to high resourced high schools and they're in good shape academically. And so it's a very different type of person.

Jason Altmire [00:09:54]:
And when you talked about the difficulty of nursing, the physical nature of it and some people just don't enjoy the work once they get into it. There's also the aspect of the people who've been in the profession for a while that are aging out. Yes, that's one of, when you look at future forecasts, that's one of the big glaring red flags for everybody. Talk a little bit about that. What, what does that mean for the future?

Karen Cox [00:10:22]:
So there's two pieces to it. The two greatest groups of people who left direct care nursing in, in a study a couple years ago were just who you said, those who, baby boomers who finally are going to retire and who've been doing direct care their whole career. So they're a different breed of nurse. And the other group leaving in the larger numbers were Those in their 20s, 30s, so the younger group. And so that really throws off all of our work that we do around predicting what we need and what we're going to have because we're assuming somebody 25 years old probably has a 30 year Runway and if they drop out, we don't have that. One of the innovative things that people are doing in healthcare systems, largely it came out of the pandemic and the shortages with that is virtual nursing where there are nurses on the ground taking care of patients, but then there's a virtual nurse sitting somewhere at a computer and, and doing a lot of the things that can be done that way to allow the person in the hospital to really focus on the physical needs and the tasks and the things that need to get done and they work together and that virtual nurse, the physical part comes out of it. Now I've talked to some people who served in that role and they say sometimes just sitting there focused on the computer is just, it feels pretty physical, but it allows them a little more Runway to work. And you know, face it, we're gonna, we lose, when we have somebody with 30 years experience, we're losing some real significant brain power.

Karen Cox [00:12:07]:
And so I think that's been one approach to it. We actually developed a course for existing nurses for a health system on how to actually practice as the virtual nurse, as the nurse on the ground, and how you work together. And so it's something that's being successfully used. It's good for retention at all levels, but it really helps for people who are on the other side of nearing retirement.

Jason Altmire [00:12:37]:
I wanted to have you on in particular, you're an expert on this issue we mentioned. You're the president of the largest provider of nursing education programs in the country. You were also president of the American Academy of Nursing. But you recently wrote an really insightful op ed in Fortune magazine, co wrote along with your counterpart who deals with physician education. But I want to talk about the nursing aspect in particular. And you've focused on innovation and you feel that in order to solve this problem and expand that pipeline of talent to fill these gaps that may exist in the future, the key is going to be innovating in the way, not only that nurses operate out in the world, the way that they conduct themselves and the technology that exists, but innovation in education, which I find really interesting. So can you talk a little bit about what you meant by that and what you talked about in that op ed?

Karen Cox [00:13:40]:
Sure. So there's some pretty standard things. Nursing programs are, you know, we're accredited, highly accredited, and there are demands of that accreditation that everyone has to meet. But above and beyond that, there are opportunities to help nurses find where they really want to work. The first year turnover rate of nurses is 30%. And you think about the cost of that to the person, orienting them to the health system, to the person themselves. It's pretty demoralizing to get through a very difficult program and then find that it's not working for you. And if you stop and think about it, we can all work anywhere with the right education or onboarding.

Karen Cox [00:14:24]:
But the person who's going to thrive in oncology may not be the one who thrives in the emergency department. And the clinical experiences in BSN programs doesn't allow for a lot of flexibility to say, well, well, you want to do oncology, let's make sure it's hard enough to get those opportunities to meet the basic criteria for accreditation. So that's difficult. So we've developed something that works, the generalist model. So nurses at a BSN are a generalist when they graduate. That's what we're educating. But what we did was incorporate something called practice ready specialty focus. And that basically gives you an opportunity for a collateral program where you take a 16 hour course on the particular specialty.

Karen Cox [00:15:17]:
And we work with the specialty organizations to develop this. So it's not just Chamberlain. So, for example, we work with ons, Oncology, Nursing Society. We have this program. If you're in good standing in your last semester or last year of your program, you take that course, you pass it. And then if you want, only if you want, your Last clinical of 96 hours can be in one of our partners oncology area. So one of two things happens. You fall in love with it and realize, yes, this is why I went to school to do this, or just as good, you say, ooh, not what I thought, not what I would enjoy.

Karen Cox [00:15:59]:
And it saves everybody. And I believe it starts your career off in a very different way if you get to that. And again, we don't charge them for it. It's voluntary. They can drop out of the course if they want at any time. If they're worried about something, their other studies. So just thinking about, well, you know, there's what we have to do and what we're credited to do, but there's also ways to really optimize the exposure that they get.

Jason Altmire [00:16:31]:
I want to make sure I heard you correctly when, when you started that, did you say that it is almost one third of people who go into the nursing profession, they don't survive past the first year.

Karen Cox [00:16:45]:
Correct. And I believe there's two reasons for it. One is the environment itself, how they're treated, how they're involved in the, the department, you know, all of those things. Their peers, I can't do in education a whole lot about that and talk about it. However, I think the other reason is they get to the wrong place and they're just like, oh my gosh, what have I done? And they're worried that it's going to look bad on their record if they leave. But they're miserable. Some areas sound a lot different than what they turn out to be. A good example is the pediatric intensive care unit.

Karen Cox [00:17:23]:
My background is in pediatrics and the pediatric intensive care unit. You're taking care of the child, the child's family, with serious conditions, of course. And the other thing that people don't realize is there are more deaths in a pediatric ICU than an adult icu just by nature of who goes in there, what their condition is upon arrival. And you know, I've seen people think that was exactly what they wanted to do. And then they go home and have nightmares or cry or just upset. And so trying to figure that out is really important to the healthcare system.

Jason Altmire [00:18:04]:
Yeah. How much does scope of practice factor into this. And by that I mean different states, but also at the federal level there are, there's a difference of agreement, difference of opinion among the physician community and nursing community about the different ways that nurses can go about their job and the scope of what they're able to do. And I know that has been a huge policy issue in the country. Does that factor in to a nurse's decision or maybe dissatisfaction with the profession?

Karen Cox [00:18:41]:
So that would be more along the lines of nurse practitioners. So somebody who's been an rn, bsn, and then goes on to get a master's degree, because that's the place where there's this discussion between medical associations, nursing associations, about where they stop and start, what's purely one and the other and where the overlap can be. And we saw in the pandemic there were states that had not allowed a very broad scope for nurse practitioners. They expanded it for the pandemic and then they went back. And I think that in and of itself is telling of the issues there. And what's fascinating is most physicians, especially those who've worked with advanced practice or nurse practitioners, they can't imagine doing without them. So it's not at the individual level, it's not so much the nursing level, it's at the associations and the states. And so you're exactly right.

Karen Cox [00:19:40]:
It's really policy. I think most nurses go into nursing because they think they want to be a nurse. Many of them go on. So I don't think it does anything at that point. But it may make a difference when they're thinking about investing all the time and energy and dollars to get an.

Jason Altmire [00:19:57]:
Advanced practice degree to kind of wrap up here. What would be your suggestion on what the nation should be doing? We have a problem right now with a shortage that exists that is going to get worse over time. You outlined some of the reasons why it's a problem. But if we were to start right now and you had ultimate decision making authority about one or two changes that we could make, what would you suggest?

Karen Cox [00:20:26]:
I think that nursing programs should be able to expand the number of students they take. That's number one. And often in most schools we're not talking about a lot of students and it doesn't produce much in the way of margin. And so it's an expensive degree because of supervising clinicals. So it's a pretty hands on program. And so to figure out ways from a policy perspective that will soften that or help that. But probably the most important thing would be that holistic admissions were A actual part of accreditation and what I mean, holistic admissions, and this has been in the literature for 15 years now, was recommended by the nursing education associations. And it says that a person is more than their gpa, whether it's in, you know, prerequisites or in high school.

Karen Cox [00:21:25]:
And not to focus so much on just taking the top. If the 3.8's the cutoff, you just take that 100 of them and go on your way. But to look at it more holistically because the role of a nurse is holistic at the end of the day and we're leaving out just a tremendous amount of people. It makes your life easier if you have those high number GPAs because they can teach themselves. In some ways they have a different level or ability to focus just on their nursing program. But it cuts out a lot of really great people. I couldn't go to my alma mater now. I did not have a 3.8.

Karen Cox [00:22:04]:
And that's where they're at right now. So I think just thinking about that and adopting more flexible models like the practice ready to really help nurses go into nursing. But stay there.

Jason Altmire [00:22:20]:
Our guest today has been Dr. Karen Cox. She is president of Chamberlain University, the largest provider of nursing education programs in the country. Dr. Cox, thank you for being with us.

Karen Cox [00:22:32]:
Thank you. My pleasure.

Jason Altmire [00:22:38]:
Thanks for joining me for this episode of the Career Education Report. Subscribe and rate us on Apple Podcasts, Google Play, Spotify or wherever you listen to podcasts. For more information, visit our website at career.org and follow us on Twitter @CECUED. That's C-E-C-U-E-D. Thank you for listening.